Background
Methods
Study design
Settings
Participants
Procedure
Phases | Description |
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Incident identification and selection | The first step of the CDM process. The participant selects an appropriate incident for probing. The participant is asked to give a detailed description of the incident from the beginning to end. For example, in this study, the ID experts identified a recent case that seemed complex to solve cognitively. |
Timeline verification and decision point identification | The second step is to get a clear and refined overview of the incident structure, key events and segments. For each of the key events, the participants were asked for goals at that point. For example, in this study, the timeline verification started from the very moment the ID expert got involved with the case or was referred to the case. |
Progressive deepening | The third step refers to points in the timeline where the interviewer probes the participants for additional details. As a result, more details about decision points, judgments and the decision-making process are revealed. This particular phase ensures that the participants are probed for specific and detailed information regarding cognitive skills, experiences and expertise. For example, in this study the experts were asked specific questions about their gut feelings and how they knew the information that suddenly occurred to them. |
“What-If” queries | In this final phase, the participants are asked hypothetical questions regarding their incidents that further help to illuminate the implicit decision-making process of the experts. For example, the interviewer asked, “If the patient had contracted a different type of pathogen, how would you have responded?” |
Data analysis
Results
Factors associated with decision-making complexity
Themes | Factors | Example quotations |
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Overall clinical picture does not match the pattern | Unexpected outcome | “So he was started on Cefotaxime. And about five days went by and he did not improve; he became more encephalopathic. He had trouble recalling not the city but the state and the country he was residing in” |
Risky patient characteristics | “So he’s on antiretroviral for his HIV. He is on two psychotropic medicines. He was in a car accident 10 years ago and had brain trauma at the time and he’s on one of the medications for improving memory” | |
Unusual case | “I’ve never seen a case of Brucellae; that was my first one. I think I may have ordered a Brucellae culture once in the past and it was negative. But I thought that the case was just very strong for that. You know, TB of course is a common thing and that would be something that it could have been as well” | |
Lack of comprehension of the situation | Lack of and/or conflicting indicator data | “You start to get a trend, and when you get 20 min of data and you have a fever in a guy with pan resistant drugs it’s scary. When you have three days of the same guy going down for a smoke break, relaxing, chilling in his room, watching TV, you’re a lot more comfortable with the plan” |
Lack of evidence about treatment effectiveness | “We knew he had stuff everywhere at one point. He was sort of stalled in his clinical improvement. We were having some slight to moderate suspicion that there’s another pocket of infection, and what was the best imaging study to get. The problem is if you asked 10 radiologists you might have gotten 10 different answers. And what really happened is he probably got a very expensive, non-specific test that then led us to do a CAT scan” | |
Lack of diagnosis | “Could he have candida endocarditis, or could he have some occult viscous rupture, like a ruptured diverticulum; something that would let all the candida in the GI tract suffuse into the peritoneal fluid where then it would grow like in a bath of mycology broth?” | |
Gaps in physicians’ knowledge | “We looked at some review papers on vertebra osteomyelitis and we looked for guidelines. There’s guidelines about to be published but they’ve not yet been published so we looked for clinical trials but didn’t find much except for some vague low-grade recommendations that you should treat until epidural collection was resolved – but that was not specified what that meant, absolutely disappear versus no longer abscess versus no longer bone involvement. So that wasn’t very helpful” | |
Social and emotional pressures | Frustration/regret | “I also see sometimes there’s a nervousness or an anxiety about stopping so they continue but they never make clear in their own minds or in the medical record why they’re anxious, why they believe their patient deserves a longer duration of therapy than standard. And I think it’s an important exercise to at least be able to clarify in your own mind why you’re doing things differently and be able to express that and argue that” |
Liability and/or fear | “This is a guy who had in the past, recent past, been critically ill on various occasions, and when you look at his microbiology it’s terrifying frankly the number of bugs he has and the various resistance” | |
Multiple care providers/conflict | “But the cardiology and the transplant team is very aware of all of these because anytime anything happens to the kidney all of their other medicines get screwed up including all the anti-rejection drugs. So they’re watching it like a hawk, you know” |
Strategies used to deal with complexity
Watchful waiting instead of prescribing antibiotics: less is more
“There was nothing that I needed to do today on that patient. Now, again, if I really thought that the risk of endocarditis was high based on the fact that she had a murmur, any other signs or stigmata of endocarditis, then we would have gotten three blood cultures before starting antibiotics.”
“And so even if it’s inappropriate, prescribing an antibiotic is felt like you’re doing something; whereas not prescribing an antibiotic is maybe the more responsible thing to do but it’s still perceived as not doing anything. So, if there’s a complication, if someone gets an antibiotic and they have a complication like say a C diff infection then ‘Eh, it’s just a complication of the antibiotics’; whereas if you don’t treat them, trying to be responsible and not treating them but then they have a complication, let’s say their infection comes back or something else happens, then people will be like, ‘Well, why didn’t you do something about it?’ So that’s your fault whereas if they got a C diff infection that’s not really your fault – that’s just the way it goes.”
Theory of mind: projection and simulation of other practitioners’ perspectives
“So, you know, I think nowadays, other clinicians might say, even if they don’t have HIV risk factors, you should test them. So, everybody with mono should probably have an HIV test. So maybe, we won’t just do unnecessary tests here.”
“You know, medicine folks would ask you, ‘Well, can we switch to oral now?’ I’m lik,e ‘No, I don’t think so.’ All the time for endocarditis, they’ll ask, ‘Can we use oral drugs? and I’m like, ‘Show me where in the world can you treat bacteremia with oral drugs, that’s where then you can treat them.’ And then the same people, if you don’t treat enough when they’re readmitting they’ll say, ‘Oh, he was insufficiently treated.’”
Heuristics: using shortcut mental model to simplify the problem
“I think usually we would consider stopping therapy in a patient who’s had six months of therapy total, IV and oral for vertebra osteomyelitis in the absence of retained prosthetic material. However, this is his second about to near death with the same pathogen and a very similar infection. He is tolerating the antibiotic very well. So, we’re considering now leaving him on oral suppressive antibiotics indefinitely.”
“So for me it’s always more important to get the right diagnosis and then to follow the guidelines if the person applies to the guidelines. So for me, I would rather initiate a really good history and physical and then secondarily, apply the guidelines to it. And we applied the guidelines and treated him as the guidelines would recommend.”
Anticipatory thinking: planning and re-planning for future events
“I think the risk/benefit analysis then would favor continuing him on antibiotics because the risk of the antibiotics themselves is very low once he’s tolerated them for a certain amount of time. And the potential consequence is if he relapses from off course then it is very severe. So, in this circumstance, I suspect I’ll probably leave him on antibiotics for quite some time.”
“The question is what can be done so that the infection does not come back. The reason why that’s a question that’s fraught with some anxiety is that in this guy there is a significant downside every time you treat him with antibiotics. Every time he gets antibiotics there were complications, and I worry that there will be more complications that we might not be prepared for.”
Seeking help: consultation with other experts for their opinions
“We have a weekly conference for the immune-compromised ID docs. We discussed his case in that conference and just reviewed everything, sought out any other opinions, any advice as to what other people might consider for evaluation or duration of therapy and tried to come up with kind of a consensus, which I think was very valuable.”
“But I will admit there have been multiple times since I’ve contacted clinicians I don’t know. I usually contact them through email. If I cannot get hold of them, then I email my colleagues, former mentors, ID physicians working here. I generally describe them about the complex case and ask them what they would do.”